Conspicuous consumption

TB is perceived as a poverty-related disease of the distant past, but it is making a comeback, especially in London, writes Laura Donnelly

There's a feeling that it's a disease of the past: Charles Dickens and all that. First of all there's the perception that tuberculosis is not a disease that nice middleclass people get.

'Second, a lot of doctors have forgotten about it, ' says Dr Ken Citron, former consultant physician at the Royal Brompton Hospital and former adviser to the Department of Health on TB.

East London and the City health authority can't afford to forget about TB. One of its boroughs, Newham, holds the dubious honour of having the highest rates of the disease in the UK: one in 1,000 people have the disease.

This week, the HA took action, with the publication of an annual health report aimed squarely at the old enemy, consumption.

Gini Gleissberg, the HA's newly appointed TB network manager, is well aware of the scale of the challenge in the East End. Her own career has taken her from nursing in London to a World Health Organisation programme looking at TB in Siberia.

'The levels of TB are actually worse in Newham, ' says Ms Gleissberg, in a revealing moment which suggests why media fears of an 'explosion of TB' are quick to ignite. 'It's not an epidemic, ' she insists. 'But the alarm needed raising.

The ante needed to be upped. It is not acceptable, in a country like England, that we have a problem like this.'

The word 'tuberculosis' is an emotive term: fading heroines in Victorian novels have seen to that. And those fears continue to create 'an explosive mix of ignorance and stigma', says director of public health Dr Bobbie Jacobson.

Which is why Dr Citron, now a trustee for TB Alert, a charity working to raise public awareness of the potential killer, believes that education will do more to stem the tide of the bacterial disease than any report, however well-meaning.

'You get a lot of doctors getting together thinking: 'Ah, we'll prepare a report.' Everybody says: 'Well, that's marvellous.' But does anything get done?'

Dr Jacobson has strong evidence to suggest that the HA's report has already had an impact. For one thing, its publication 'coincided' with an announcement from the DoH that it would be reinstating its BCG schools vaccination programme in London - suspended nationally last September - in recognition of the capital's high TB rates. Does Dr Jacobson think the timing was coincidental? She cannot hide a splutter: 'No I do not. My chair said just now we should congratulate ourselves on having made sure that this particular part of the TB puzzle has been resolved and kept in the eye of the DoH.

'If we have been influential in this decision, then well and good.'

A victory, then, although Dr Jacobson admits 'it has not yet been made clear to me' which types of vaccinations will be back in place and when.

The HA's report also flags up a key role for education. Dr Jacobson says the sort of stigma associated with TB makes it 'ripe for a pan-London education programme', before admitting there is 'no money to support that in the next year'.

But Dr Citron admits that ignorance is not confined to those outside the medical community. TB Alert is currently pursuing a number of court cases against GPs who have failed to correctly diagnose patients.

Dr Citron says: 'A young doctor can go through the whole of his medical training without ever coming across a case of TB. It can be missed, and it can present in curious ways - all sorts of lumps and bumps.'

Corry Van den Bosch, the HA's lead consultant in communicable diseases, flags up problems persuading patients to stick to treatment regimes which can mean juggling several drugs - some with unpleasant side effects - over six to nine months.

'The problem is magnified when it comes to 'issues of lifestyle' and the difficulties in sticking to a daily routine for those sleeping rough or moving on regularly. That is why the HA wants to increase the ratio of specialist TB nurses to patients.

Ms Gleissberg says: 'It's why it is important to have a tailor-made package for patients so they are getting the support they need.

'In a few cases the side-effects can be unpleasant and they can feel pretty sick. That's why TB nurses are vital.'

Financial penalties are being lifted from high-profile standards including cancer and elective waiting times, so far without attracting much attention. How is this happening? And will it work, asks Rob Findlay